| Abstract|| |
Background: Little evidence is available regarding the dental health of victims of chemical warfare in Iran. Therefore, in this study, we examined the decayed, missing, and filled teeth index (DMFT), community periodontal index of treatment needs (CPITN), and saliva secretion rate of chemical warfare victims living in the province of Isfahan in Iran.
Materials and Methods: This case-control study was conducted with 300 chemical warfare victims as the treatment group and 300 age-matched individuals without exposure to chemical warfare as the control group. DMFT and CPITN indices and saliva secretion rate were measured and compared between the two groups.
Results: Chemical warfare victims had significantly higher scores than the control group for decayed teeth (4.25±3.88 vs 3.52±2.81; P=0.009), missing teeth (8.79±9.3 vs 6.15±8.43; P<0.001), total DMFT index (17.00±6.72 vs 13.20±6.89; P<0.001), and CPTIN (2.81±0.81 vs 1.71±1.04; P<0.001). However, no significant difference was observed between the two groups in filled teeth (4.00±4.2 vs 3.59±2.48; P=0.148). The level of saliva secretion in warfare victims was significantly lower than that in the control group (1.71±0.05 vs 3.85±1.95 cc/5 min; P<0.001).
Conclusion: Chemical warfare victims have relatively poor dental/oral health. Chemical injury might cause a dysfunction in saliva secretion, with decrease in saliva secretion increasing the risk for tooth decay and periodontal disorders. Further research is required to find out the exact underlying mechanisms and the factors associated with poor dental/oral health in chemical warfare victims.
Keywords: Community periodontal index of treatment needs, chemical warfare victims, decayed, missing, and filled teeth index, saliva
|How to cite this article:|
Mottaghi A, Hoseinzade A, Zamani E, Araghizade HA. Status of dental health in chemical warfare victims: The case of Isfahan, Iran. Indian J Dent Res 2012;23:506-8
The prevalence of teeth decay and periodontal diseases is commonly influenced by lifestyle, behavioral, and environmental risk factors.  War veterans represent a group with high risk for various pathological conditions in the oral cavity. Previous studies have shown that war can play a role in periodontal and temporomandibular disorders. ,, In addition to physical and psychosocial stressors, chemical agents may also affect the health of war veterans; this is unfortunately what happened during the war between Iran and Iraq (1980-1988). The role of some chemical agents in periodontal diseases has been examined in previous studies but the results are controversial. Evaluation of oral health among those occupationally exposed to chemical agents has shown increased prevalence of periodontal disease, mouth soreness, teeth looseness and, in one instance, increased number of missing teeth.  McCauley and colleagues  examined the relationship between low-dose exposure to anticholinesterase agents and periodontal disease in Gulf War veterans who were possibly exposed to chemical warfare agents. They found that exposure to low-doses of these agents does not, by itself, increase the risk for periodontal disease. Similarly, another study done among Gulf War veterans who were possibly exposed to organophosphate chemical warfare agents reported that the studied veterans were not at increased risk of health symptoms possibly associated with low-dose exposure to chemical warfare agents; although, increased symptomology was observed in veterans who were close enough to participate in or witness the detonations. 
|How to cite this URL:|
Mottaghi A, Hoseinzade A, Zamani E, Araghizade HA. Status of dental health in chemical warfare victims: The case of Isfahan, Iran. Indian J Dent Res [serial online] 2012 [cited 2019 Oct 23];23:506-8. Available from: http://www.ijdr.in/text.asp?2012/23/4/506/104959
Despite the importance of oral health and its socioeconomic impact on chemical warfare victims, little evidence is available on dental health in this group. Therefore, we designed this study to assess the oral and dental health status of chemical warfare victims in the province of Isfahan in Iran.
| Methods and Materials|| |
Participants and setting
This cross-sectional study was conducted from the year 2010 to 2011 at the Department of Oral and Maxillofacial Surgery, School of Dentistry, Islamic Azad University, Khorasgan Branch (Isfahan), Iran. All chemical warfare victims who were living in Isfahan at the time of study were invited through public announcement to participate in the research. Those who had diabetes or a smoking background were excluded. Thus, 300 male participants with an average age of 44±7.9 years were included in the study. For the control group, we selected 300 individuals without exposure to chemical warfare from the population of Isfahan city. The study was approved by the Ethnical Committee of the Isfahan School of Dental Medicine. Written consent was obtained from all participants.
First, the decayed, missing, and filled teeth index (DMFT), the community periodontal index of treatment needs (CPITN), and saliva secretion rate were assessed. DMFT and CPITN measurements were recorded using a dental mirror and a special World Health Organization (WHO) CPI probe under an independent light source, according to the WHO recommendation for basic surveys in dentistry.  The amount of saliva secretion was measured by collection of saliva in a graduated test tube every 60 seconds for 5 minutes, and the secretion rate was expressed as milliliters per 5 minutes.
SPSS software version 16.0 was used for statistical analysis. The Mann-Whitney and independent samples t-test were used for analysis of the data. P<0.05 was considered to be statistically significant in all analyses.
| Results|| |
The comparison of DMFT and its components, CPITN, and saliva secretion rate between the treatment and control groups are presented in [Table 1]. The mean DMFT index was significantly higher (P<0.001) in chemical warfare victims than in the control group. Two components of the DMFT index-decayed teeth (P<0.05) and missing teeth (P<0.001)-were also significantly higher in the chemical warfare victims group; no significant difference was, however, detected between the two groups in filled teeth (P=0.148). The mean CPITN was also higher in the chemical warfare victims than in the control group (P<0.001). The mean saliva secretion rate in the chemical warfare victims was significantly lower than that in the control group (P<0.001).
| Discussion|| |
The aim of current study was to evaluate the oral/dental health status in chemical warfare victims in the province of Isfahan, Iran. The DMFT index and CPITN were significantly higher in chemical warfare victims than in the normal population. Saliva secretion was lower in chemical warfare victims. An earlier study revealed that environmental and behavioral factors have influences on oral/dental health status, and that the prevalences of tooth decay and periodontal diseases are generally related to behavioral risk factors.  War is a stressor that has significant impact on the lifestyles of those involved.
Suman et al. in their study of professional soldiers in the Croatian army clearly showed that the soldiers who participated in the war in Croatia had higher values of DMFT and CPITN than the soldiers who presented their services in peacetime. The researchers also discovered significant differences between the soldiers who did their military service during war and those whose service was during peacetime; the differences were seen in three areas:
This could be interpreted as indicating that these factors are important underlying mechanisms for poor oral/dental health status in war veterans. The authors also suggested that with regard to oral diseases, soldiers can generally be considered as a high-risk group because military training and the time spent in the battlefield require their maximal psychological and physical involvement.  Problems such as the lack of a normal life and hard/unusual work conditions, especially during the war, result in unbalanced food intake, irregular hygiene, and stress. All these could be causes for the increase in oral diseases in war victims.
- the number of dental visits;
- daily brushing frequency, and
Chemical warfare victims, in addition to the usual physical/psychological stresses associated with war are also exposed to chemical agents, which only increases the risk for oral/dental diseases. The role of chemical agents on periodontal diseases has been described in previous studies. Adverse effects such as erosion, periodontal disease, soreness of the mouth, looseness of teeth, and increased number of missing teeth have been reported among workers exposed to chemical agents. , However, there are only a few studies on the oral/dental health status among chemical warfare victims, and the findings from these studies are somewhat controversial. McCauley et al. examined the relationship between low-dose exposure to anticholinesterase agents and subsequent periodontal disease in Gulf War veterans who were possibly exposed to chemical warfare agents. In contrast to our results, they found that exposure to these agents does not appear to be a risk factor for periodontal diseases. This discrepancy between the two studies is perhaps related to our control group who was selected from the normal population and the fact that participation in the war by itself can influence oral/dental health status. Thus, the perceived differences between chemical warfare victims and the healthy control group in this study might not directly be due to chemical exposure. In another study done on Gulf War veterans who were possibly exposed to organophosphate chemical warfare agents, the investigators found that war veterans were not at increased risk of having health symptoms attributable to low-dose exposure to chemical warfare agents. Nonetheless, enhanced symptomatology was observed in veterans who were adequately close to participate in or witness detonations. 
The mechanisms underlying poor oral/dental health status in war veterans is of great importance. Decrease in saliva secretion is a likely mechanism. In this study we followed a simple methodology for assessment of saliva secretion. This method was chosen because other measurement procedures were less satisfactory for this study population. Furthermore, this collection method has been previously shown to be valid, reliable, and susceptible.  Our findings showed that the amount of saliva secretion was lower in chemical warfare victims than in healthy controls. This finding is consistent with the hypothesis that chemical exposure in war can disturb salivary function, which in turn can lead to tooth decay and periodontal disorders. Other factors such as psychological disorders (frequently seen in war victims) and the use of antipsychotic drugs might also have contributed to the lower saliva secretion seen in chemical warfare victims.
This study has some limitations. Our control group was selected from the normal population of Isfahan city whereas, ideally, the control group should have been composed of war veterans who participated in the war but were not exposed to chemical agents. Also, it would have been better if we had devised a method to score the degree of participation in war and exposure to chemical agents and then measured the association with oral/dental health; this would have allowed measurement of any dose-response relationships. Mechanisms other than decrease in saliva secretion, e.g., differences in behavioral factors, lifestyle, diet, etc., were not evaluated in this study. Further research on this subject must take these factors into account.
| Conclusion|| |
It could be concluded from this study that chemical warfare victims have relatively poor dental/oral health. Chemical exposure might cause a dysfunction in saliva secretion, which may in turn play an important role in the increase in tooth decay and periodontal disorders. Further investigations are needed to find out the exact underlying mechanisms and the factors associated with poor dental/oral health status in this population so that preventive strategies can be formulated.
| References|| |
|1.||Winston AE, Bhaskar SN. Caries prevention in 21 st century. J Am Dent Assoc 1998;129:1579-87. |
|2.||Jankovic B, Ciglar I, Knezevic A, Juriæ H, Bukoviæ D, Staniciæ T. Caries and oral hygiene in children in postwar Novi Travnik (Bosnia and Herzegovina) and Zabok (Croatia). Coll Antropol 2004;28:439-45. |
|3.||Uhac I, Kovac Z, Valentic-Peruzovic M, Juretiæ M, Moro LJ, Grziæ R. The influence of war stress on the prevalence of signs and symptoms of temporomandibular disorders. J Oral Rehabil 2003;30:211-7. |
|4.||Akopov SE, Toromanian EN, Kankanian AP, Van Dorne P, Sarkisian MA. The clinicobiochemical characteristics of periodontal diseases in subjects who are under conditions of constant, permanent stress. Stomatologiia (Mosk) 1996;75:30-2. |
|5.||Neal PA, Jones RR. Chronic mercurialism in hatters' furcutting industry. JAMA 1938;110:337-42. |
|6.||McCauley LA, Lasarev M, Sticker D, Rischitelli DG, Spencer PS. Illness Experience of Gulf War Veterans Possibly Exposed to Chemical Warfare Agents. Am J Prev Med 2002;23:200-6. |
|7.||McCauley L, Rischitelli G, Lambert W, Lasarev M, Sticker D, Spencer P. Symptoms of Gulf war veterans possibly exposed to organophosphate chemical warfare agents at Khamisiyah, Iraq. Int J Occup Environ Health 2001;7:79-89. |
|8.||Gray G, Smith T, Knoke J, Heller J. The postwar hospitalization experience of Gulf War veterans possibly exposed to chemical munitions destruction at Khamisiyah, Iraq. Am J Epidemiol 1999;150:532-40. |
|9.||Iowa Persian Gulf Study Group. Self-reported illness and health status among Gulf War Veterans. JAMA 1997;277:238-45. |
|10.||Bamise CT, Esan TA, Ajayi JO, Olagundoye O, Oziegbe EO. Dental erosion in a road-side battery technician: case report and a review of the literature. Oral Health Prev Dent 2008;6:249-53. |
|11.||Holland RI, Ellingsen DG, Olstad ML, Kjuus H. Dental health in workers previously exposed to mercury vapour at a chloralkali plant. Occup Environ Med 1994;51:656-9. |
|12.||White KD. Saliva: A review and experimental investigation of major techniques. Psychophysiology 1977;14:203-12. |
Department of Oral and Maxillofacial Surgery, School of Dentistry, Islamic Azad University, Khorasgan Branch (Isfahan)
Source of Support: None, Conflict of Interest: None